Lamotrigine Augmentation of Serotonin Reuptake Inhibitors in Severe and Long-Term Treatment-Resistant Obsessive-Compulsive Disorder

Manuel Arrojo-Romero,María Tajes Alonso,Jose De Leon

doi:10.1155/2013/612459

Abstract

The treatment recommendations in obsessive-compulsive disorder (OCD) after lack of response to selective serotonin reuptake inhibitors (SSRIs) include augmentation with other drugs, particularly clomipramine, a more potent serotonin reuptake inhibitor (SRI), or antipsychotics. We present two cases of response to lamotrigine augmentation in treatment-refractory OCD; each received multiple SRI trials over a >10-year period. The first patient had eleven years of treatment with multiple combinations including clomipramine and SSRIs. She had a >50% decrease of Y-BOCS (from 29 to 14) by augmenting paroxetine (60 mg/day) with lamotrigine (100 mg/day). The second patient had 22 years of treatment with multiple combinations, including combinations of SSRIs with clomipramine and risperidone. She had an almost 50% decrease of Y-BOCS (from 30 to 16) and disappearance of tics by augmenting clomipramine (225 mg/d) with lamotrigine (200 mg/day). These two patients were characterized by lack of response to multiple treatments, making a placebo response to lamotrigine augmentation unlikely. Prospective randomized trials in treatment-resistant OCD patients who do not respond to combinations of SSRIs with clomipramine and/or antipsychotics are needed, including augmentation with lamotrigine. Until these trials are available, our cases suggest that clinicians may consider lamotrigine augmentation in such treatment-resistant OCD patients.

Highlights

There is general agreement in the obsessive-compulsive disorder (OCD) literature that the first line for pharmacological treatment is the selective serotonin reuptake inhibitors (SSRIs)
Twentyfour weeks after the initial visit, at the fifth visit with the same cognitive behavioral therapy (CBT) and taking paroxetine (60 mg/day), lamotrigine (100 mg/day), and clonazepam, the patient reported a complete disappearance of psychosocial stressors and improvement in OCD symptoms (Y-BOCS total score = 14)
It is important to stress that (1) the patient had 22 years of prior treatments including no obvious response to combinations of SSRI plus clomipramine and SSRI plus risperidone, making a placebo response to lamotrigine augmentation unlikely, and (2) the response to lamotrigine augmentation was dramatic with a 47% decrease in Y-BOCS total score and disappearance of the tics

Summary

Introduction

There is general agreement in the obsessive-compulsive disorder (OCD) literature that the first line for pharmacological treatment is the selective serotonin reuptake inhibitors (SSRIs). Bruno et al [12] conducted a 16-week double-blind, randomized, and placebo-controlled trial of lamotrigine augmentation (up to 100 mg/day) in patients receiving SSRIs. The patient had an adequate SSRI trial for at least 12 weeks and was still having enough OCD symptoms, as determined by a Yale-Brown Obsessive-Compulsive Scale [13, 14] (Y-BOCS) score >16. We describe two cases of marked response to lamotrigine augmentation in open treatment, assessed by the same psychiatrist (the first author) These two cases are important because they include patients who were treatmentrefractory and received multiple SRIs trials over a >10-year period, making the possibility of placebo response unlikely

Case Presentations

Discussion

Findings

Disclosure